Great Oaks Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Great Oaks Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689May 22, 2025

  Based on observations, resident, staff, and family interviews, record review, and facility policy review, the facility failed to maintain a safe environment and provide adequate supervision and equipment to prevent accidents for one (1) of four (4) sampled residents. Resident #1. Specifically, staff removed the resident's bed rails without a safety assessment and as a result, the resident rolled out of bed, during care and sustained a head laceration, suffered pain and required emergency room treatment, including x-rays and stitches. […]

• No harm, potential for more than minimal, patternF725Oct 1, 2024

  Based on resident and staff interviews, record review, and facility policy review the facility failed to provide sufficient staffing to ensure residents needs were met in a timely manner for five (5) of seven (7) residents reviewed. Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7. Findings Include: Record review of the facility policy, Staffing, Sufficient and Competent Nursing with reviewed date of 03/2023 revealed, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. […]

• No harm, potential for more than minimal, patternF880Jan 4, 2024

  Based on observation, staff interview, record review, and facility policy review the facility failed to prevent the potential spread of infection when staff failed to sanitize hands between a respiratory treatment and peg (percutaneous endoscopic gastrostomy) tube medication administration and failed to clean and properly store a respiratory mask and peg tube syringe for (1) one of (8) resident care observations. Resident #15 Findings include: Review of the facility policy titled, Administering Medication, revised April 2019, revealed Policy heading: Medications are administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation: 25.) Staff follows established facility infection control procedures (e.g. […]

• No harm, potential for more than minimal, isolatedF640May 20, 2026

  Based on record review, staff interview, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted within CMS (Centers for Medicare and Medicaid Services) required time frames for one (1) of 14 MDS assessments reviewed. Resident #30.Findings Include:Record review of CMS Version 3.0 Manual revealed under Chapter 5, Submission and Correction of the MDS Assessments.5.2 Timeliness Criteria. For all non-admission OBRA (Omnibus Budget Reconciliation Act) and PPS (Prospective Payment System) assessments, the MDS Completion Date must be no later than 14 days after the Assessment Reference Date (ARD).For Entry and Death in Facility tracking records, the MDS Completion Date must be no later than 7 days from the Event Date.An interview… […]

• No harm, potential for more than minimal, isolatedF580Nov 6, 2025

  Based on record review and staff interview, the facility failed to notify the provider to clarify missing orders for previously established interventions following a resident's return from the hospital. This resulted in a lapse in continuity of care for one (1) of three (3) residents reviewed for hospital readmission. Resident # 1.Findings Include: Record review of July 2025 Order Summary Report for Resident #1 revealed an abduction pillow, and nutritional supplement was ordered prior to hospital transfer on 8/15/25. Review of the After Visit Summary dated 8/18/2025 showed no mention of these interventions. Upon readmission, the facility did not contact the provider to clarify whether the interventions should be resumed, and the interventions were not reinstated. […]